Provider Demographics
NPI:1639457823
Name:KOON, JUSTIN T (PHD)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:T
Last Name:KOON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2437 MINERAL SPRINGS RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29072-9145
Mailing Address - Country:US
Mailing Address - Phone:803-520-8295
Mailing Address - Fax:803-520-8298
Practice Address - Street 1:2437 MINERAL SPRINGS RD
Practice Address - Street 2:SUITE C
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072-9145
Practice Address - Country:US
Practice Address - Phone:803-520-8295
Practice Address - Fax:803-520-8298
Is Sole Proprietor?:No
Enumeration Date:2011-07-22
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5343106H00000X
FLIMT1490106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist